Every day, pharmacists sidestep potential mix-ups while they're filling prescriptions-perhaps the doctor's scrawl is hard to decipher or sometimes the drug bottle is mistaken for another that looks awfully similar.
In most cases, errors are caught and corrected before that pill bottle ever reaches the customer.
But now, for the first time, those near-misses are being reported to the Institute for Safe Medication Practices (ISMP) Canada in a unique pilot project called SafetyNET. In the first eight months of a year-long study, 813 near-misses were counted among 13 participating pharmacies in Nova Scotia. The pharmacies range from small rural independents, to grocery store pharmacies and large chains.
"It's a very sensitive topic because no one wants to make a mistake-especially in these types of cases, because a mistake can affect someone's health," says Neil MacKinnon, SafetyNET's co-principal investigator and associate professor with the College of Pharmacy at Dalhousie University in Halifax, Nova Scotia. He also notes that in the health care system's "culture of blame," reporting medication errors could get you fired or reprimanded.
There is currently no mandatory system for reporting medication errors. And yet, the potential for problems is huge: Dr. MacKinnon says 453 million prescriptions were dispensed in Canada last year. It's estimated that one in 11 emergency room visits by seniors are due to medication errors.
But without reporting, it is difficult, if not impossible, to make the system better: to catch that error that slips through checks and double-checks and harms someone's health. As well as reporting near-misses, participating pharmacies are holding quarterly staff meetings to discuss errors and make improvements.
"Pharmacies are busy places and pharmacists are always being interrupted-you're doing one thing and switching to something else, for example, answering the phone or talking to a customer," says Sandeep Sodhi, pharmacist and co-owner of Village Family Pharmacy in Bible Hill, N.S. "So there's the potential to make errors. The good thing about SafetyNET is that it helps us identify where the problems are occurring and to do so something about it."
The most common errors caught by the SafetyNET study have involved dosage problems. Other problems have included: